Differential Diagnosis in Clinical Examination R Deenadayalan
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General ExaminationChapter 1

 
FEVER
  1. How fever is beneficial?
    1. Leukocytes show maximum phagocytic activity between 38-40°C
    2. During fever the circulating iron level goes down. Iron is helpful for the growth and reproduction of bacteria. So, when circulating iron level goes down, bacterial growth is prevented
    3. Fever produces direct inhibiting effect on certain viruses like polio and coxsackie viruses.
  2. How fever causes weight reduction?
    1. ↑ BMR
    2. ↑ protein breakdown (catabolism)
    3. Water loss
    4. Anorexia (loss of appetite)
  3. Fever blisters (Herpes simplex) seen in
    1. Pneumonia
    2. Malaria
    3. Streptococcal infections
    4. Meningococcal infections
    5. Rickettsial fever
      2
    Rare in
    1. Typhoid
    2. TB
    3. Smallpox
    4. Mycoplasma pneumoniae
  4. Beneficial effects of fever
    1. Neurosyphilis
    2. Some forms of chronic arthritis
    3. Gonorrhea
    4. Malignancy—In fever there is release of endogenous pyrogens which activate T cells and this enhances host defense mechanism.
  5. Ill effects of fever
    1. Epileptiform fits
    2. Weight loss
    3. Sweating causes salt and water depletion
    4. Depletion – Dehydration – Delirium
  6. Fever without infection
    1. Pontine hemorrhage
    2. Factitious fever
    3. Habitual hyperthermia
    4. Drugs – Atropine, etc.
    5. Malignancy – Leukemia, Hodgkin, etc.
    6. Rheumatological disorders, e.g. SLE, rheumatoid arthritis, etc.
  7. Fever in cardiovascular system disorders
    1. Rheumatic fever
    2. Infective endocarditis
    3. Atrial myxoma
    4. (TB) pericarditis (effusion)
    5. Polyarteritis nodosa
      3
    6. Myocardial infarction
    7. Pulmonary thromboembolism
    8. CCF
    9. Temporal arteritis
  8. Fever in respiratory system disorders
    1. Pyogenic infectious of lung – suppurative
    2. Bronchitis
    3. Pneumoconiosis
    4. Pneumonia
    5. Pleurasy
  9. Fever in gastrointestinal tract disorders (abdominal)
    1. TB peritonitis and TB abdomen
    2. Crohn's disease
    3. Acute appendicitis
    4. Subdiaphragmatic abscess
    5. Perinephric abscess
  10. Fever in liver disorders
    1. Infective hepatitis – preicteric stage
    2. Amoebic liver abscess
    3. Malignancy
    4. Cholecystitis
  11. Fever with malignant disorders
    1. Hypernephroma
    2. Ca pancreas
    3. Ca lung
    4. Ca bone
    5. Hepatoma
    6. Hodgkin
    7. Non-Hodgkin's lymphoma
    8. Acute leukemias
      4
  12. Fever in hematological disorders
    1. Hodgkin's disease
    2. Infections mononucleosis
    3. Blood transfusion reactions (mismatched)
    4. Hemorrhage into body cavities
    5. Septicemic conditions
  13. Fever in neurological disorder
    1. Meningitis
    2. Encephalitis
    3. Cerebral abscess
    4. Poliomyelitis – early stage
    5. Acute polyneuritis
    6. Head injury
    7. Pontine hemorrhage
    8. Cerebral malaria
  14. Causes of fever with sweating
    1. Malaria
    2. TB
    3. RS
    : Lung abscess
    Branchiectasis – acute stage
    Pneumonia
    4. CVS
    : Infective endocarditis
    Myocardial infarction
    Aterial myxoma
    5. Renal
    : Pyelonephritis
    6. Others
    : Filariasis
    Any pyogenic infection
  15. Special forms of fever
    1. Charcot's fever
      In acute cholecystitis with inflammation of the cystic duct, the patient is afebrile in daytime. But, evening temperature 5shoots up to 105°F accompanied by chills. This is called Charcot's fever.
    b. Pel-Ebstein fever
    – Fever lasting for 7–10 days and afebrile for about a week.
    c. Pretibial fever
    – Leptospirosis
    d. Factitious fever
    – Patient develops fever voluntarily by infecting contaminated material
    e. Habitual
    – Fever with normal sedimentation rate.
    hyperthermia
    Usually occurs in young female
    f. Black water fever
    – Malaria
    g. Black fever
    – Kala-azar
    h. Brake bone fever
    – Dengue
    1. 1°F rise of temperature raises the BMR by 7%
    2. 1°F rise of temperature ↑ the heart rate by 10 beats
    3. Heart rate is increased by a maximum of 15 beats per minute during pregnancy.
  16. Fever in muscle disorders
    1. Polymyositis
    2. Born holm disease
    3. Crush injury to muscles
  17. Fever in bone and joint involvements
    1. Osteomyelitis – acute
    2. Arthritis
      1. Rheumatoid
      2. Rheumatic
      3. Pyogenic
    3. Malignancy – Osteosarcoma
  18. Fever in renal disorders
    1. Acute glomerulonephritis
    2. Pyelonephritis
    3. Cystitis
    4. UTI
      6
      Infection without fever
    1. Immunosuppressed patients.
  19. Types of fever
    1. Continuous
    – Fever is present continuously.
    Fluctuation of temperature is <1°F
    2. Remittent
    – Fever present. Fluctuation >2°F
    3. Intermittent
    – Fever present intermittently.
  20. Causes of remittent fever
    1. Typhoid
    2. Infective endocarditis
    3. Kala-azar
    4. Plague (Remiteant or continuous)
    5. Infectious mononucleosis
    6. TB
  21. Causes of continuous fever (sustained fever)
    1. Pneumonia
  22. Causes of intermittent fever
    1. Malaria
  23. Causes of hyperthermia
    1. Heat stroke
    2. Hyperthyroidism
    3. Sepsis
    4. Pontine hemorrhage
    5. Anticholinergic drug overdose
 
HYPOTHERMIA
  1. Causes of hypothermia
    1. Pituitary insufficiency
    2. Addison's disease
    3. Hypoglycemia
      7
    4. Cerebrovascular disease
    5. Myocardial infarction
    6. Cirrhosis
    7. Pancreatitis
    8. Alcohol
    9. Drugs – Barbiturates, alcohol, phenothiazines
    10. Exposure to cold
    11. Hypothyroidism
    12. Wernicke's encephalopathy
 
DELIRIUM
  1. Causes of delirium
    1. Fever
    2. Head injury
    3. Uremia
    4. Liver cell failure
    5. Hypoxia
    6. Hyponatremia
    7. Postictal state
    8. Drugs – Alcohol (withdrawal), Atropine
    9. Senility
 
MEDICAL CAUSES OF ITCHING
  1. Medical causes of itching (pruritus)
    1. Cholestatic jaundice (more at nights)
    2. Primary biliary cirrhosis
    3. Hodgkin's disease
    4. Uremia – chronic renal failure
    5. Diabetes mellitus
    6. Hyperthyroidism and hypothyroidism
    7. Polycythemia rubra vera – especially after a hot bath
    8. Advanced stages of pregnancy due to intrahepatic cholestatis
      8
    9. Sleeping sickness
    10. Malignancy – leukemia – myloma
    11. Psychogenic
    12. Senile pruritus
    13. Drugs – Aspirin, opium derivatives, quinine, penicillin, sulfa group of drugs
    14. Onchocercus volvulus
    15. Carcinoid syndrome
    16. Iron deficiency
  2. If there is rubella infection in the antenatal period the child will have:
    1. Mental deficiency
    2. Nerve deafness
    3. Cataract
    4. Patent ductus arteriosus
    5. Pulmonary stenosis
    6. Pulmonary artery branch stenosis
 
SKIN PIGMENTATION
  1. Causes of palmar erythema
    1. Chronic liver disease
    2. Long standing cases of rheumatoid arthritis
    3. Thyrotoxicosis
    4. During pregnancy – disappears after delivery
    5. Chronic leukemia
    6. Chronic fever
    7. Alcoholism
    8. SLE
    9. Polycythemia
  2. Skin pigmentations seen in (including oral cavity)
    1. Chronic renal disease
    2. Chronic liver disease
      9
    3. Malabsorption syndrome
    4. Addison's disease
    5. Peutz-Zager syndrome
  3. Causes of spider naevi
    1. Liver disorders – Hepatic encephalopathy
    2. Rheumatoid arthritis
    3. Pregnancy appears between 2-5th month – disappears after delivery
    4. Sometimes in normal individuals (Here it is less than 5 in number)
  4. Causes of flapping tremor
    1. Hepatic failure
    2. Chronic renal disease
    3. Cardiac failure
    4. Respiratory failure
  5. Causes of malar flush
    1. Mitral stenosis
    2. Lupus erythematosis
  6. Striae of skin of abdominal wall
    (Due to rupture of elastic fibers of skin)
    • Multiparus women
    • In multiparus women if there is sudden↑in abdominal size like
    • Abdominal tumor
    • Obesity
    • Cushing syndrome
  7. Causes of yellowish discoloration of skin
    1. Jaundice
    2. Carotene pigments
    3. Quinacrine
      10
    4. Atabrine
      Slight degrees of bilurubin is first seen near the franulum of the tongue.
  8. Causes of graying of hair (Loss of formation of melanocytes)
    1. Aging
    2. Hereditary
    3. Albinism
    4. Pernicious anemia
    5. Over vitiligo
    6. Chloroquine toxicity
    7. Associated with B12 deficiency (Megaloblastic anemias)
    Macule:
    Up to 1 cm, circumscribed flat discoloration not palpable
    e.g. Flat naevi
    Petechiae
    Purpura
    Drug eruption
    Rubella, rubeola, typhoid, rheumatic fever, etc.
    Papules:
    Up to 1 cm, circumscribed elevated superficial solid lesion
    e.g. Elevated naevi
    Warts
    Secondary syphilis
    Chickenpox, Smallpox, etc.
    Nodules
    : Up to 1 cm, may be in level with or above or beneath the skin surface.
    e.g. Xanthoma
    Secondary syphilis
    Epithelioma
    Erythema nodosum
    Vesicles:
    Up to 1 cm, circumscribed elevated, contain serous fluid
    e.g. Chickenpox – Smallpox – Herpes zoster
    11
    Bullae
    : Larger than 1 cm. Circumscribed, elevated contain serous fluid
    e.g. Burns and Scalds
    Purpura
    Petechiae
    Ecchymoses
    Up to 2 cm in size
    1–2 mm size
    2–5 mm size
  9. Causes of hyperpigmentation of skin
    1. Scleroderma
    2. Addison's disease
    3. Cirrhosis liver
    4. Hemochromotasis
    5. Fetty's syndrome
    6. Pernicious anemia
    7. Folic acid deficiency
    8. Malnutrition
    9. Starvation
    10. Porphyria lutea
    11. Drugs:
      Busulphan
      Arsenical
    12. Pellagra
    13. Malignancy (internal)
    14. Irradiation
    15. Alkaptonuria
    16. Arsenic poisoning
    17. Post dermal kala-azar
    18. Onchocerca volvulus
  10. Causes of hypopigmented patches
    1. Tenia versicolor leprosy
    2. Vitiligo
    3. Leprosy
  11. Causes of blushing of skin
    1. Emotional
    2. Fever
      12
    3. Hyperthyroidism
    4. Carcinoid tumor
    5. Drugs allergy
    6. Hypercapnia (Exessive CO2 in blood)
  12. Causes of ichthyosis
    1. Lepromatous leprosy
    2. Hodgkin's disease
    3. Malabsorption
    4. Vitamin A deficiency
    5. Hypothyroid state
    6. Pellagra
    7. Refsum's disease – rare
    8. Congenital
  13. Some of the autoimmune disorders
    1. Hashimoto's thyroiditis
    2. Addison's disease
    3. Thyrotoxicosis
    4. Primary atrophic hypothyroidism
    5. Idiopathic hypoparathyroidism
    6. Insulin dependent diabetes
    7. Pernicious anemia
    8. Rheumatic fever
  14. Raynaud phenomena seen in (Collagen vascular disorders)
    1. Scleroderma
    2. Disseminated lupus erythematosis
    3. Rheumatoid arthritis
    4. Dermatomyositis
    5. Primary pulmonary hypertension (in early stages)
    6. Myeloma
    7. Atrial myxoma
    8. Thoracic outlet syndrome
    9. Shoulder hand syndrome
      13
    10. Drugs: Reserpine and methyldopa, guanethidine
    11. Primary systemic sclerosis
    12. CREST syndrome
    13. Polymyosities
    14. Sjögren's syndrome
      Color changes – Palar, cyanosis, erythemia
      Symptoms are: 1. Numbness,2. Tingling,3. Burning sensation
  15. Cafe au lait spots seen in
    1. Multiple neurofibroma
    2. Albright's syndrome
  16. Pallor without anemia
    1. Shock
    2. Myocardial infarction
  17. Causes of intermittent jaundice
    1. Drugs like–Methyldopa, oral contraceptives, salicylates, INH, Chloramphenicol, carbon tetrachloride, trichloroethylene
    2. Acute intermittent porphyria
    3. Migrating worms obstructing the ampulla of Vater
    4. Inflammatory edema of ampulla of Vater
    5. Gallstones intermittently obstructing the bile duct
    6. Spasm of bile duct
    7. Fever like malaria – RBC destruction
    8. III trimester of pregnancy
    9. Transient formation in pulmonary thromboembolism
    10. Lobar pneumonia
  18. Causes of bigger teeth
    1. Maternal diabetes mellitus
    2. Maternal hypothyroidism
    3. Big baby
      Small teeth
    1. Darwin syndrome
      14
  19. Fear of swallowing (Odynophasia)
    1. Rabies
    2. Tetanus
    3. Hysteria
    4. Pharyngeal paralysis due to fear of aspiration
    5. Painful esophagitis
  20. Causes of erythema nodosum
    1. Leprosy
    2. Rheumatic fever
    3. Tuberculosis
    4. Sarcoidosis
    5. Fungal infections
      • coccidioidomycosis
      • histoplasmosis
    6. Infection with hemolytic Streptococcus
    7. Cat scratch fever
    8. Drugs like – Sulfathiazole
  21. Diseases spread by dogs
    1. Rabies
    2. Hydatid disease
    3. Tetanus
    4. Asthma by allergy
    5. Leptospirosis
    6. Brucellosis
    7. Blastomycosis
  22. Diseases spread by cats
    1. Toxoplasmosis
    2. Rabies
    3. Asthma by allergy
    4. Cat scratch fever
    5. Tularemia
      15
  23. Diseases spread by rats
    1. Plague
    2. Leptospirosis
    3. Tetanus
    4. Asthma by allergy
    5. Weil's disease
  24. Diseases spread by laboratory animals
    1. Asthma
    2. Toxoplasmosis
    3. Rabies
  25. Diseases spread by fish
    1. Food allergy
    2. Food poisoning
    3. Asthma
    4. Allergic skin lesions
    5. Diphyllobothrium latum—fish tapeworm
  26. Diseases spread by pigs
    1. Cysticercosis – Tapeworm
    2. Encephalitis
    3. Brucellosis
    4. Leptospirosis
  27. Parasites producing eye lesions
    1. Toxoplasma
    2. Onchocercus volvulus
    3. Loa Loa
  28. The hormones (only two) which are not controlled by other hormones (Other endocrine glands)
    1. Parathyroid hormone
    2. Insulin
  29. Blue sclera
    1. Osteogenesis imperfecta
    2. Marfan syndrome
      16
    3. Iron deficiency anemia
    4. Pseudohypoparathyroidism
    5. Newborn and young children (Normal)
  30. Spider naevi seen in
    1. Hepatic failure
    2. Rheumatoid arthritis
    3. Normally (Particularly in children) – Rare
    4. Pregnancy (Appear between 2nd and 5th month and disappear within 2 months after delivery)
  31. NAILS (Transverse ridges)
    1. Beau's lines
    → Trauma, systemic stress
    2. Terry's nail
    → Cirrhosis (Tips-pink proximate white)
    3. Mee's lines
    → Hypoalbuminuria parallel white transverse lines
    4. Lindsay's nail
    → Renal failure, distal red proximal white
    5. Onycholysis
    → Fungal infection/psoriasis/
    hyperthyroidism
    6. Spoon nails
    → Iron deficiency anemia
    Lichen planus
    Hypothyroidism
    Syphilis
    Coronary arterial disease
    Rheumatic fever
    7. Subungual splinter hemorrhage
    → Infective endocarditis
    8. Clubbing
    → Parrot-beak appearance
    9. Wider nail
    → Acromegaly
    10. Long narrow nail
    → Hypopituitarism
    11. Yellow nail syndrome
    → Nail plates yellow
    12. Hypoplastic nail
    → Turner's syndrome
    13. Eggshell nail
    → Syphilis
    17
    14. Hippocratic nails
    →Respiratory and circulatory disease/cirrhosis
    15. Brittle nail (Onychorrhexis)
    →The free end of nail is laminated and irregular seen inhypocalcemic malnutrition
  32. Nails
    1. Rate of growth of nail is 0.5 mm per week (0.1 mm per day)
    2. Nail growth is faster in summer than in winter
    3. Nails in hands grow about 4 times faster than nails in toes
    4. Nails of long fingers grow more rapid than in small fingers
    5. It is an analog of clear in the lower arrivals
  33. Causes of Dupuytren's Contracture: (One or both sides may be affected) (palmar fibrosis)
    1. Alcoholic liver disease
    2. Trauma
    3. Epilepsy
    4. Old age
    5. Diabetes mellitus
    6. May be hereditary
  34. Causes of generalized lymphadenopathy
    1. Lymphatic leukemia
    2. Lymphoreticular malignancy
    3. Secondary syphilis
    4. Measles
    5. Infectious mononucleosis
    6. Sarcoidosis
    7. Toxoplasmosis
  35. Causes of bilateral exophthalmos
    1. Thyrotoxicosis
    2. Craniostenosis
    3. Acromegaly
      18
    4. Myxedema
    5. Cavernous sinus thrombosis
    6. Hyperpituitarism
    7. Lymphomas
    8. Leukemia
  36. Causes of unilateral exophthalmos
    1. Cavernous sinus thrombosis
    2. Primary tumors within the orbit
    3. Retro-orbital intracranial tumors
    4. Diseases of nasal air sinuses (mucococle, carcinoma)
    5. Arteriovenous aneurysms
    6. Thyrotoxicosis
    7. Myxedema
  37. Polydactyly (supernumerary fingers)
    zoom view
    • Laurence-Moon-Biedl syndrome
    • Juvenile obesity
    • Retinal degeneration
    • Genital hypoplasia
    • Mental retardation
  38. Koilonychia causes (spoon nails)
    1. Iron deficiency anemia
    2. Syphilis
    3. Lichen planus
    4. Rheumatic fever
    5. Hypothyroidism
    6. Fungal dermatosis
  39. Causes of big lips
    1. Cretinism
      19
    2. Myxedema
    3. Acromegaly
  40. Hutchinson's triard
    1. Hutchinson's teeth
    2. Interstitial keratitis
    3. Labyrinthine deafness
  41. Causes of saddle nose
    1. Syphilis
    2. Leprosy
    3. Wegener's granuloma
    4. Achondroplasia
    5. Fracture nasal bone
    6. Hurler's syndrome
    7. Down syndrome
  42. S.No.
    KF ring
    Arcus senilis
    1.
    Cornea between ring and limbus is normal
    Cornea seen between ring and limbus
    2.
    May be interrupted
    Continuous
    3.
    Golden brown in color
    Grayish white
    4.
    Seen in the desmous membrane
    5.
    Always pathological
    Physiological
    6.
    Better seen in slit-lamps examination
    Can be seen by naked eye
  43. Causes of pescavus
    1. Fredrick's ataxia
    2. Peroneal muscular atrophy
    3. Spina bifida occulta
    4. Hereditary spastic paraplegia
    5. Roussy-Lévy syndrome
      20
    6. Myelodysplasia
    7. Syringomyelia
    8. Hereditary motor sensory neuropathy type I
  44. Causes of pesplanus
    1. Marfan's syndrome
    2. Ehlers-Danlos syndrome
    3. Osteogenesis imperfecta
  45. Friedreich's foot: High arch foot with hammer toes seen in Friedreich's ataxia.
  46. Causes of kyphoscoliosis
    1. Spinocerebellar degeneration – Fredericton's ataxia
    2. Torsion dystonia
    3. Marfan's syndrome
    4. Homocystinuria
    5. Poliomyelitis
    6. Syringomyelia
    7. Progressive spinal vascular atrophy
    8. TB spine/Tumors of spine
    9. CV anomaly
    10. Senile osteoporosis
    11. Ankylosing spondylitis
    12. Paget's disease
    13. Acromegaly
    14. Rickets
  47. Neonate
    Below one month
    Infancy
    0–2 years
    Childhood
    2–10 years
    Adolescence
    10–20 years
    Youth
    20–35 years
    Middle age
    35–55 years
    Old age
    55 and above
    21
    Presenile
    <65 years
    Senile
    >65 years
  48. Exaggerated lumbar lordosis causes
    1. Muscular dystrophy
    2. Massive ascites
    3. Massive abdominal tumors
    4. Advanced stages of pregnancy
  49. Pseudomyotonia both contraction and relaxation are delayed but more in relaxation
    1. Hypothyroidism
    2. Diabetes mellitus
    3. Pernicious anemia
    4. Hypothermia
    5. Peripheral vascular disease
    6. Anorexia nervosa
    7. Ankle edema
  50. Hammer toes seen in
    1. Marfan syndrome
    2. Hereditary motor sensory neuropathy type I
    3. Friedreich's ataxia
  51. KF ring seen in
    1. Wilson's disease
    2. Primary biliary cirrhosis
    3. Sclerosing cholangitis
  52. Carpal-tunnel syndrome seen in (pain will be more at night)
    1. Acromegaly
    2. Hypothyroidism
    3. Pregnancy
    4. Amyloidosis
    5. Sarcoidosis
    6. Rheumatoid arthritis
      22
  53. Vitiligo is seen in the following systemic disorders
    1. Hashimoto's thyroiditis
    2. Pernicious anemia
    3. Addison's disease
    4. Diabetes mellitus
    5. Uveitis
  54. Absent lateral eyebrows
    1. Hypothyroidism
    2. SLE
    3. Iatrogenic
    4. Drugs
  55. Causes of central retinal artery occlusion
    1. Carotid artery emboli
    2. Giant cell arteritis
    3. Emboli from heart
  56. Causes of central retinal vein occlusion
    1. HBP
    2. Atherosclerosis
    3. Hyperviscosity syndrome
      • Dysproteinemias
      • Blood dyscratic
  57. Causes of retinal neovascularization
    1. Diabetes mellitus
    2. Hemoglobinopathies
  58. Causes of esophageal candidiasis
    1. Systemic illnessc
      • Immunocompromised state HIV
      • Diabetes mellitus
      • Hematological malignancy
      • Achalasia cardia
      • SLE
      • Alcoholism
        23
      • zoom view
  59. Causes of retinitis pigmentosa
    1. Refsum's diseases
    2. Abetalipoproteinemia
    3. Laurence-Moon-Bardet-Biedl syndrome
  60. Carotenoderma
    (Carotene is converted to vitamin A in liver. For this thyroid hormone is necessary)
    So carotenemia can occur in
    1. Myxedema
    2. Liver diseases
  61. Dupuytren's contracture
    1. Progressive fibrosis of palmar fascia resulting in painless flexion contracture of fingers.
    2. Ring finger is first affected and most prominently involved. Then little finger, middle finger, index finger and thumb.
    3. Puckering of palmar skin is typical.
    4. Sometimes there may be modulus in the palmar fascia.
    5. Seen more in B ♂and than in ♀
    6. Appears after the age of 25 years.
    7. Seen in liver disease, epilepsy old age, diabetes mellitus.
    8. Occasionally occurs as familial.
 
CANCER
  1. Name some of the precancerous conditions
    1. Leukoplakia
    2. Junctional nervus
      24
    3. Xeroderma pigmentosa
    4. Gluten enteropathy
  2. Oncogenic tissues (viruses causing tumors)
    • 1. Epstein-Barr virus → Burkitt's lymphoma
    • zoom view
    • 4. Herpes simplex virus →carcinoma cervix(HSV2)
  3. Tumor blush (due to new vessel formation) seen in
    1. Hepatoma – primary
    2. Hypernephroma
 
SMELL
    1. Fruity or abnormal smell – Diabetic ketosis
    2. Ammoniacal odor – uremia
    3. Musty odor (fetor Hepatitis) – liver failure
    4. Alcoholic smell – Alcoholism
    5. Halitosis
      – Bad breath, e.g. starvation
      Gingivitis
      Suppurative lung disease
  1. Different odors and diseases
    1. Halitosis
    →Suppurative lung disease
    2. Fruity odor
    →DKA
    3. Ammoniacal odor
    →Renal failure
    4. Mousy or fishy
    →Liver cell failure
    Odor/Feter Hepaticas
    5. Bitter almond or silver
    →Cyanide poisoning
    polish odor of breath
    6. Alcoholic odor
    →Alcohol ingestation
    25
 
SWEATING
  1. Pathological causes of sweating
    1. Pyrexia
    2. TB – during sleep (evening)
    3. Pyogenic infection
    4. Hyperthyroidism ↑ BMR
    5. Fluid – blood loss shock
    6. Hypoglycemia
    7. Psychoneurosis
    8. Pheochromocytoma
 
JOINTS
  1. Charcot joint: Causes
    1. Tabes dorsalis
    2. Syringomyelia
    3. Hereditary sensory neuropathy
    4. Charcot-Marrie-Tooth disease
    5. Familial dysautonomia
    6. Diabetes mellitus
    7. Leprosy
    8. Spina bifida
    9. Prolonged local steroid therapy
    10. Congenital insensitivity to pain
    11. Trauma
  2. Carpal-tunnel syndrome Seen in:
    1. Myxedema
    2. Rheumatoid arthritis
    3. Amyloidosis
    4. Acromegaly
    5. Trauma
    6. Premenstrual edema
      26
    7. Edema of pregnancy
    8. Progressive systemic sclerosis
    9. Mucopolysaccharidosis
    10. Tenosynovitis of flexor tendonitis of wrist
    11. Diabetes mellitus →neuropathy
    12. Ca bronchus
  3. Causes of perforation of nasal system
    1. Syphilis (posterior perforation)
    2. Lepromatous leprosy
    3. Intranasal trauma
    4. Chromium poisoning
    5. Tuberculosis (anterior perforation)
    6. Lupus erythematosus
    7. Workers involved in chrome plating
    8. Inhalation of dust containing arsenic
    9. Rheumatoid arthritis
    10. Wegener's granulomatosis
    11. Progressive systemic sclerosis (PSS)
  4. Causes of deformity of skull
    1. Hydrocephalus
    2. Oxycephaly
    3. Paget's diseases
    4. Apert's syndrome
    5. Rickets
    6. Congenital syphilis
    7. Tumor of skull bones
    8. Thalassemia major – bossing of skull
    9. Hurler's syndrome (large and boat-shaped head)
  5. Typical face abnormalities seen in:
    1. Hansen disease
    2. Acromegaly
      27
    3. Nephrotic syndrome
    4. Cushing syndrome
    5. Myxedema
    6. Parkinsonism
    7. Pseudobulbar palsy
    8. Facial palsy
    9. Facial hermiatrophy
    10. Scleroderma
    11. Tetanus
    12. Mikulicz syndrome
    13. Congenital syphilis
  6. Causes of alopecia
    1. Hereditary
    2. Syphilis
    3. Diabetes mellitus
    4. Fungus of scalp and pediculosis
    5. Pituitary insufficiency Simmonds’ disease
    6. Irradiation
    7. Cytotoxic drugs
    8. Dystrophia myotonia
    9. Typhoid – rare
    10. Chemicals; thallium
    11. Deficiency of zinc
    12. Werner's syndrome
  7. Hutchinson's triad (Characteristic of congenital syphilis)
    1. Hutchinson's teeth
    2. Interstitial keratitis
    3. Labyrinthine disease (causing deafness)
  8. Perforation of the palate
    1. Syphilis
    2. Irradiation
    3. Congenital
      28
  9. High orched palate
    1. Marfan syndrome
    2. Turner syndrome
    3. Myotonic dystrophy
    4. Rubinstein Taybi syndrome
    5. Achondroplasia
  10. Vincent's angina (Trench mouth)
    Infection of tonsil and gums usually unilateral causes necrosis with a dirty yellow exudate; when removed causes bleeding. DD– syphilis, diphtheria. Tender painful gingivatis. Bleeding on pressure.
  11. Ludwig's angina
    Swelling of floor of mouth, elevation of tongue, difficulty in swallowing and breathing. Submaxillary space, sublingual space and submental space are involved due to infections.
  12. Cause of webneck (and low hairline)
    1. Klippel-Feil syndrome
    2. Turner syndrome
    3. Ullrich Noonan syndrome
    4. Pseudohypoparathyroidism
    5. Pseudohypoparathyroidism
  13. Cause of bony (sternal) tenderness (It is a sign of expansion of bone marrow)
    1. Leukemia's
    2. Myeloproliferative disorders
    3. Severe anemia
    4. Multiple myeloma
    5. Hodgkin's disease
    6. Secondaries
  14. Causes of tall stature
    1. Constitution of body – because of tall parents
    2. Children with thyrotoxicosis (Before epiphytical fusion)
      29
    3. Klinefelter's syndrome
    4. Pituitary adenoma
    5. Acromegaly
    6. Gigantism
    7. Marfan syndrome
  15. Causes of dwarfism
    1. Constitutional delay in growth
    2. Genetic Noonan syndrome – Fanconi syndrome
    3. Nutritional
      1. Deficiency intake
      2. Intestinal malabsorption
      3. Chronic renal disease – renal rickets
      4. Chronic infestation
      5. Protein losing disorders
    4. Hypoxia
      1. Congenital cyanotic heart disease
      2. Chronic pulmonary diseases
    5. Chromosomal abnormalities
      1. Down syndrome
      2. Turner syndrome
    6. Skeletal disorders
      1. Achondroplasia
      2. Hurler's syndrome
    7. Endocrine disorders
      1. Hypopituitarism
      2. Hypothyroidism – cretinism
      3. Cushing's disease
    8. Trace elements deficiency
      Hypogonadal dwarfisms
  16. Causes of bilateral enlargements of parotids
    1. Mumps
    2. Sarcoidosis
      30
    3. Mickulicz syndrome – painless
    4. Cirrhosis (alcoholic) liver
    5. Sjögren's syndrome
    6. Malnutrition – Kwashiorkor
    7. Leukemia
    8. Lymphoma
    9. Drugs and chemicals – iodine, mercury, lead
    10. HIV
    11. Thyrotoxicosis
  17. Unilateral enlargement of parotids
    1. Obstruction of parotid duct (stenosis duct)
    2. Typhoid
    3. Parotitis
    4. Leukemia
  18. Monkey face seen in
    1. Marasmus
    2. Hypertrichosis lanugosa (also known as dog face)
  19. Moon face seen in
    1. Protein energy malnutrition
    2. Cushing's syndrome
  20. Rheumatoid factor will be positive in the following conditions
    1. Rheumatoid arthritis
    2. Systemic lupus erythematosus
    3. Sjögren's syndrome
    4. Polymyositis
    5. Scleroderma
    6. TB
    7. Leprosy (Lepromatous and Tuberculosis)
    8. Syphilis
    9. Infective endocarditis
    10. Viral hepatitis
      31
    11. Infectious mononucleosis
    12. Parasitic infestations
    13. Pneumoconiosis
    14. Scleroderma
    15. Drug abusers
    16. Chronic active hepatitis
    17. Cirrhosis liver
    18. Idiopathic pulmonary fibrosis
    19. Lymphomas
    20. Repeated blood transfusion
    21. Typhoid
  21. Conditions causing early morning stiffness and pain in joints
    1. Rheumatoid arthritis
    2. Ankylosing spondylitis
  22. Causes of shoulder hand syndrome
    1. Myocardial infarction
    2. Trauma
    3. Hemiplegia
    4. Degenerative joint disease of cervical spine – cervical spondylitis
 
LYMPH NODE
  1. Supraclavicular lymphadenitis in (left lower lobe involvement cause right supraclavicular lymphadenopathy)
    1. Cancer stomach–on left side lymph nodes
    2. Sarcoidosis
    3. Reticulosis
    4. TB
    5. Lung cancer
    6. Tumor of testes – on left side
      32
  2. 1. Subcutaneous nodules
    → Rheumatic fever
    2. Osler nodes
    → Infective endocarditis
    3. Rheumatoid nodules
    → Rheumatoid arthritis
    4. Heberden's nodes
    → Degenerative joint
    disease/Osteoarthritis
    5. Bouchard's nodes
    → Degenerative joint
    disease/Osteoarthritis
    6. Warty nodules on feet and legs
    → Pretibial mycoderma
    7. Painless firm fibrous nodes
    over bony pronmenus
    → Yaws
    8. Haygarth's nodes: Spindleshaped enlargement of proximal
    interphalangeal joints
    → Rheumatoid arthritis
    9. Xanthelasma
    → Hypercholesterolemia
    Brownish yellow
    Around eyes
    10. Xanthoma
    →Also in hands
 
TESTES
  1. Causes of primary testicular atrophy: Pituitary function is normal – but testicular function is impaired
    1. Trauma to testes
    2. TB infection of testes
    3. Syphilis
    4. Gonorrhea
    5. As a complication orchitis following mumps
    6. Surgical removal
    7. Undescended testes
    8. Irradiation
    9. Drugs
  2. Causes of secondary testicular failure
    1. Pituitary disorders
    2. Congenital–chromosomal abnormality–Klinefelter syndrome
      33
    3. Cirrhosis liver (Alcohol)
    4. Hemochromatosis (By producing cirrhosis)
    5. Mumps
    6. Lepromatous leprosy
    7. Myotonia dystrophia
    8. zoom view
      Testicular atrophy (Evidence):
      1. Small testes (Normal size is 2 × 3 × 4 cm)
      2. Soft in consistency
      3. Absence of testicular sensation
 
ENDOCRINE
  1. Causes of impotence
    1. Psychological
    2. Diabetes mellitus
    3. Alcoholism
    4. Tabes dorsalis
    5. Disseminated sclerosis
    6. Spinal infection
    7. Friedreich's ataxia
    8. Hypopituitarism
    9. Hypogonadism
    10. Testicular atrophy
    11. Dystrophia Myotonic
    12. Irradiation
    13. Lepromatous leprosy
    14. Subacute combined degeneration of the cord
    15. MND
    16. Drugs
    17. Hemochromatosis
      34
  2. Causes of loss of libido
    1. Psychogenic
    2. Cirrhosis liver
    3. Hemochromatosis
    4. Dystrophia myotonic
  3. Causes of gynecomastia
    1. Cirrhosis liver
    2. Lepromatous leprosy
    3. Hemochromatosis
    4. Myotonic dystrophy
    5. Klinefelter syndrome
    6. Estrogen secreting tumors of adrenal gland
    7. Testicular atrophy
    8. In males at puberty
    9. African human trypanosomiasis
    10. Drugs:
      1. Estrogen for cancer prostate
      2. Digitalis
      3. Spironolactone
      4. Cimetidine
      5. Alpha methyldopa
      6. Reserpine
      7. Busulfan
    11. Hepatoma – painful gynecomastia
    12. Hyperthyroidism
    13. Leukemia
    14. Lymphoma
    15. Bronchogenic carcinoma (adenocarcinoma and large cell carcinoma)
    16. Prostatic malignancy treatment with estrogen
  4. Alpha fetoprotein seen in
    1. Hepatoma
    2. Embryonal tumor of testes
      35
    3. Epithelial carcinoma of foregut (especially stomach)
    4. Nonmalignant liver – Acute viral hepatitis
      disorders like – Active chronic hepatitis
    5. Ataxia telangiectasia (Louis-Bar syndrome)
    6. Hepatoblastoma
  5. Low ceruloplasmin level seen in
    1. Wilson's disease
    2. Fulminant hepatic failure
    3. Severe chronic liver failure
    4. Protein losing enteropathy
    5. Malabsorption syndrome
  6. Causes of ↑serum amylase
    1. Pancreatitis – Acute stage only
    2. Perforated peptic ulcer →Peritonitis
    3. Intestinal obstruction
    4. Pseudocyst of pancreas (here there is persistant elevation)
    5. Salivary gland tumors
  7. Causes of hypocalcemia:
    1. Hypoparathyroidism
    2. Malabsorption syndrome
    3. Osteomalacia due to true vitamin D deficiency or vitamin D resistance
    4. Renal failure
    5. Hypoproteinemia
    6. Pancreatitis – acute stage
  8. Causes of hypercalcemia
    1. Primary hyperparathyroidism
    2. Internal malignancy (with bone metastasis)
    3. Sarcoidosis
    4. Multiple myeloma
    5. Hypervitaminosis D
      36
    6. Milk alkali syndrome (Burnett syndrome)
    7. Adrenal insufficiency
    8. Paget's disease
    9. Idiopathic hypocalcemia of infancy
    10. Thyrotoxicosis – rare
  9. ↑of catecholamines
    1. Pheochromocytoma
    2. Hypertension
    3. Infective polyneuritis
    4. Hypothyroidism
    5. Hypoglycemia
    6. Vigorous physical activity
    7. Acute myocardial infarction
    8. Diabetic ketoacidosis
    9. Depression
    10. Duodenal ulcer
  10. Causes of ↑ BMR (Hypermetabolic state)
    1. Thyrotoxicosis
    2. Pheochromocytoma
    3. Fever
  11. Patients appear older than normal age
    1. Progeria
    2. Heavy chronic smoking
    3. Chronic exposure to sunlight (Rapid skin changes)
  12. Patients appear young than normal age
    1. Hypogonadism
    2. Panhypopituitarism
 
PAIN
  1. Seronegative arthritis
    1. Ankylosing spondylitis
    2. Reiter's syndrome
      37
    3. Psoriasis arthritis
    4. Arthritis associated with ulcerative colitis and Crohn's diseases
  2. Causes of headache (Pain and or discomfort from orbit to occiput)
    1. Meningitis
    2. Intracranial tumor/abscess
    3. Migraine
    4. Subarachnoid hemorrhage
    5. Temporal arteritis
    6. Tic douloureux
    7. Glaucoma/refractive error
    8. Intracranial AV malformation
    9. RS causes
      • COPD (due to CO2 retention)
      • Pneumonia
    10. CVS causes
      • Infective endocarditis
      • Pulmonary embolism
      • CCF
    11. Drugs and chemicals
      • Oral contraceptives
      • Nitrates (Vasodilators)
      • CO
      • CO2
      • Ethanol
        Withdrawal of drugs like
      • Ergot
      • Amphetamine
      • Clonidine
      • β-blockers
    12. Following LP
    13. Hypoglycemia
      38
    14. Pseudotumor cerebri
    15. Premenstrual headache
    16. Anemia with Hb <10 g%
    17. Hypertensive if the diastolic BP is more than 110 mm Hg
  3. Causes of frontal headache
    1. Sinusitis
    2. Ocular causes
    3. Frontal tumor
    4. Migraine
  4. Causes of occipital headache
    1. Meningitis
    2. Subarachnoid hemorrhage
    3. Tension headache
    4. Intracerebral hemorrhage
  5. Causes of unilateral headache
    1. Migraine
    2. Temporal arthritis
    3. Trigeminal neuralgia
  6. Causes of pain in face
    1. Trigeminal neuralgia
    2. Postherpetic neuralgia
    3. Sinusitis
    4. Migraine
    5. Costen's syndrome (Temporomandibular arthritis)
    6. Malignancy of face/secondaries
    7. Pathology in oropharynx/teeth
    8. Glossopharyngeal neuralgia
    9. Cavernous sinus thrombosis
    10. Painful ophthalmoplegia
    11. Tolosa-Hunt syndrome
    12. Carotidynia
      39
  7. Causes of burning feet syndrome
    1. Vitamin deficiency
    2. Renal failure
    3. Diabetes mellitus
    4. Alcoholism
    5. As a result of toxic, metabolic and inherited disorders
  8. Causes of shoulder pain (Referred pain)
    1. Myocardial infarction
    2. Subdiaphragmatic abscess
    3. Diaphragmatic pleurisy
    4. Acute pancreatitis
    5. Ruptured spleen
    6. Some cases of appendicitis with peritonitis
  9. Causes of muscle cramps (painful shortening of muscle associated with palpable knotting)
    1. Idiopathic (occurs at night at rest)
    2. During pregnancy
    3. Unaccustomed exertion
    4. Diarrhea and severe dehydration (hyponatremia, hypocalcemic, hypomagnesemia)
    5. McArdle's disease
    6. Uremia
    7. Drugs
      • Nifedipine
      • Nicotinic acid
      • Cinetidine
      • Morphine
      • Diuretics
  10. Causes of priapism
    1. Chronic myeloid leukemia
    2. Rabies – Furious type (due to involvement of amygdaloidal nucleus)
      40
    3. Local causes:
      Thrombosis
      Hemorrhage of penis
      Neoplasm
    4. Sickle cell anemia
    5. Paraplegia (Paraplegia inflexion)
    6. High cord compression (in the cervical region)
 
BLOOD PRESSURE
  1. Causes of orthostatic hypotension (Postural hypotension) BP ↓ on standing
    1. Intravascular volume contraction
      • Hemorrhage
      • Severe chronic anemia
      • Sodium depletion
      • Pregnancy
    2. CNS lesions
      • CVA
      • Trauma
      • Infection
      • Demyelination
      • Spinal cord lesions–syingomyelia/tabes dorsalis
    3. Pheochromocytoma
    4. Shy-Drager syndrome
    5. Aldosteronism
    6. Drugs – Vasodilators
      • Nitroglycerine
      • Hydralazine
      • Minoxidil
      Other drugs:
      • Tricylicanti depressant
      • Phenothiazines
        41
 
BODY DEVELOPMENT
  1. Causes of kyphosis
    1. Senile osteoporosis
    2. Ankylosing spondylitis
    3. Paget's disease
    4. Acromegaly
    5. Diseases of vertebra – TB vertebra → Gibbus (Pott's disease)
 
PARASITE
  1. Parasites producing CVS disorders
    1. Hydatid
    →Cyst, CCF, Strokes-Adamssyndrome/conduction disturbances
    2. Schistosomiasis
    →Primary pulmonary hypertension
    3. Filariasis
    →1. Primary pulmonary hypertension
    2. Myocarditis
    4. Trypanosoma cruzi
    →Myocarditis
    (Chaga's disease)
    Arrhythmias
    RBBB
    5. Trypanosomiasis
    →Myocarditis
    (Sleeping sickness)
    Pulmonary edema
    CCF
    Pericardial effusion
    6. Toxoplasmosis
    →Myocarditis
    Pericarditis/effusion
    CCF
    Arrhythmias
    Adams-Strokes syndrome
    7. Malarial parasites
    →Angina
    Coronary vascular occlusion
    8. Leishmaniasis (Kala-azar)
    →CCF
    42
    9. Amoebiasis pericardial effusion
    →Pericarditis, myocarditis,
    10. Trichinella spiralis
    →CCF/Arrhythmia
 
CIGARETTE SMOKING
  1. Harmful effects of cigarette smoking (Nicotine)
    CVS
    : Angina↑platelet adhesiveness  atheromatosis plaque Myocardial infarction↑level of carboxyl Hb CAHD/sudden death Coronary arterial spasm
    RS
    : Chronic bronchitis, bronchiectasis, pulmonary emphysema Malignancy→Squamous cell and oat cell carcinoma Lungs, oral cavity larynx, esophagus bladder, kidney, pancreas COPD
    Vascular
    : TAO
    GIT
    : Loss of appetite
    Gastric ulcer
    DU
    Pancreatic malignancy
    Others
    : Early menopause
    Spontaneous abortion in pregnant women
    Low birth weight babies
    Fetal death
  2. Active ingredient of tobacco is nicotine
    1. A standard cigarette contains about 20 mg of nicotine
    2. Smoker inhales about 2 mg of nicotine while smoking one cigarette
    3. Lethal dose of oral nicotine is 1 mg/kg body weight
    43
  3. Side effects of oral contraceptives
    1. Thrombophlebitis
    2. Thromboembolism – pulmonary
    3. Hypertension
    4. Stroke
    5. Myocardial infarction
    6. Pulmonary hypertension
  4. Hypercalcemic states
    1. Primary hyperparathyroidism
    2. Milk alkali syndrome
    3. Hypervitaminosis D
    4. Sarcoidosis
    5. Hyperthyroidism
    6. Cushing's syndrome
    7. Neoplasm – paraneoplastic syndrome in Coburg's carcinoma
    8. Multiple mycoma
  5. Causes of low uric acid level in blood
    • 1. Xanthinuria → due to deficiency of xanthers oxidase
    • zoom view
 
SKELETON
  1. Pesplanus seen in
    1. Ehlers-Danlos syndrome
    2. Marfan sydrome
    3. Osteogenesis imperfecta
  2. Frontal baldness
    1. Myotonic dystrophy
    2. Progeria
    3. Werner's syndrome
      44
  3. Small chin
    1. Williams’ syndrome
    2. Turner's syndrome
    3. Fetal alcohol syndrome
  4. Teeth abnormalities
    1. Peg teeth – Hurler's syndrome
    2. Hutchinson teeth – Peg-shaped notching/incissors
    3. Malformation of teeth – Williams’ syndrome
    4. Teeth present at birth – Ellis-van Creveld syndrome
 
EXAMINATION OF HEAD
  1. Cause of bruit over the skull
    1. Carotid cavernous fistula
    2. AV fistula of cerebral vessels
    3. Cerebral vascular malformation
    4. Brain tumor
    5. Intracranial sacular aneurysms
    6. Paget's disease of bone
    7. Angioma of scalp
    8. Sturge-Weber syndrome
      If the carotids are occluded the bruit may be ↓or absent
    9. Carotid or aortic stenosis
    10. Young children – not significant
      Bruit is very uncommon over berry aneurysm.
      Bruit in CNS
      Auscultation over
      1. Both temporal bones
      2. On the lateral occipital region
      3. Over each closed eye
      4. Over mastoid abscess and jugular veins
  2. Causes of involuntary movements of head
    1. Old age
    2. Aortic leak – DeMusset's sign
      45
    3. Parkinsonism
    4. Habit spasm
    5. Chorea
    6. Torticollis
 
CHEST
  1. Mantoux will be negative in
    1. TB abdomen
    2. Miliary TB
    3. Extensive advanced PT
    4. PT with viral infection like chickenpox
    5. TB patients who are on immunosuppressive drugs
    6. TB patients on steroid therapy
    7. With other associated diseases like leukemia, lymphoma, etc.
 
ALCOHOL
  1. Diseases in which the symptoms are more after drinking alcohol
    1. Gout
    2. Hodgkin's disease
    3. Acute intermittent prophyria
    4. Epilepsy
    5. Pancreatitis
    6. Migraine
  2. Causes of bone pain
    1. Chronic myeloid leukemia
    2. Sickle cell disease
    3. Myelosclerosis
    4. Gout
    5. Secondaries (varcinomatous infiltrations)
    6. Multiple myeloma
      46
    7. Osteoporosis
    8. Osteomalacia
 
BLOOD
  1. Causes of bleeding gums
    1. Leukemia – particularly monocytic type
    2. Agranulocytosis
    3. Thrombocytopenic states
    4. Snake bite – viper
    5. Vitamin C deficiency
    6. Hemophilia
    7. Purpura
    8. Acute and chronic renal failure
 
LUNGS
  1. Chest disorders mimicking abdominal pathology
    1. Diaphragmatic pleurisy
    2. Lower lobe pneumonia
    3. Pericarditis
    4. Pleural effusion
    5. Myocardial infarction
  2. Abdominal causes of tachypnea
    1. Appendicitis
    2. Peritonitis
    3. Intestinal obstruction
    4. Intra-abdominal hemorrhage
 
INFECTION
  1. Treponema pallidum can be isolated
    1. Ocular fluid
    2. Spinal fluid
      47
    3. Liver
    4. Lymph node
    5. Ascending and arch of aorta
 
EAR
  1. Causes of tinnitus
    1. Mèniére's disease
    2. Labyrinthritis
    3. Hypertension
    4. Acoustic neuroma
    5. Diabetes mellitus
    6. Drugs – Aspirin
 
GAIT
  1. Conditions where toe walking is not possible
    1. Parkinsonism
    2. Sensory ataxia
    3. Spastic hemiplegia
    4. Paralysis of soleus or gastric venous
    5. Cerebellar degeneration
 
EYE
  1. Medical causes of cataract
    1. Diabetes mellitus
    2. Galactosamine
    3. Hypoparathyroidism
    4. Myotonic dystrophy
    5. Marfan's syndrome
    6. Mangolism
    7. Homocystinuria
    8. Drugs: Corticosteroids
    9. Irradiation
      48
 
GASTROINTESTINAL (GI) TRACT
  1. Fungus affecting esophagus
    1. Candida albicans
    2. Aspergillus
    3. Cryptococcus
    4. Histoplasma
 
DIABETES
  1. Raised glucose tolerance arise (Diabetic) seen in
    1. Diabetes mellitus
    2. Atherosclerosis
    3. Pituitary over activity
    4. Adrenal over activity
    5. Liver damage
 
BIOCHEMISTRY
  1. ↑levels of serum cholesterol
    1. Nephrotic syndrome
    2. Myxedema
    3. Diabetes mellitus
    4. Hypercholesterolemia
    5. Biliary cirrhosis
  2. Causes of ↑serum alkaline phosphates (Disease of bone, liver and intestine)
    1. Paget's disease of bone (all disease with extensive involvement of bone producing osteoblastic activity)
    2. Hereditary hyperphosphatasia
    3. Liver disorders –
      Biliary obstruction
      Cirrhosis liver
      Secondary deposits
    4. Rickets and osteomalacia
      49
    5. Fibrous dysplasia (Albright's syndrome)
    6. Primary hyperparathyroidism
    7. Metastatic tumor of prone producing osteoblastic activity
    8. Rarely oral contraceptives by producing liver damage
    9. Osteogenic sarcoma
    10. Primary biliary cirrhosis
    11. Hypernephroma in some cases
    12. Prostatic carcinoma
    13. Lymphomas
    14. Infectious mononucleosis
    15. Miliary TB
 
VOMITING
  1. CNS causes of vomiting (↑ICT)
    1. Meningitis
    2. Encephalitis
    3. Acute hydrocephalus
    4. zoom view
    5. Acute labyrinthitis
    6. Mèniére's disease
    7. Migraine
    8. Tabetic crisis
  2. CVS causes of vomiting
    1. CCF
    2. Posterior wall myocardial infarction
    3. Drugs – Digitalis
  3. Endocrine causes of vomiting
    1. Diabetic acidosis
    2. Adrenal insufficiency – adrenal crisis
    3. Morning sickness of pregnancy
      50
  4. CNS causes of vomiting
    1. Meningitis
    2. Encephalitis ↑ICT
    3. Intracranial tumors
    4. Hydrocephalus
    5. Migraine
    6. Motion sickness
    7. Labyrinthitis
    8. Vestibular disorder
    9. Ménière's diseases
  5. GIT causes of vomiting
    1. Acute gastroenteritis
    2. Appendicitis
    3. Intestinal obstruction
    4. Peritonitis
    5. Biliary colic
  6. Renal causes of vomiting
    1. Pyelonephritis
    2. Ulcerative colitis
  7. Drugs producing vomiting
    1. Digoxin
  8. Respiratory causes of vomiting
    1. Viral infections
 
MISCELLANEOUS
  1. Causes of relative bradycardia
    1. Typhoid
    2. Legionnaires’ disease
    3. Some viral infections
      51
  2. Sudden arrest of breathing during inspiration
    1. Infection of pleura
    2. Diaphragmatic pathology – subdiaphragmatic abscess
    3. Acute cholecystitis – Murphy's sign
  3. Abdominal angina
    Ischemia of abdominal viscera due to one or more regional arteries. Trial of symptoms. Postprandial pain, associated weight loss. Diarrhea may be present. Short systolic bruit and in the epigastric or umbilical regions.
  4. Patients who are not advisable to fly in an aircraft (unpressurised)
    1. Hemoglobin trait
    2. Tension pneumothorax
  5. Tumors (Primary and secondary) seen in
    Primary tumors
    Secondary tumors seen in
    1. Lungs
    Brain, bone, liver, adrenal, spinal cord
    2. Liver
    Bone (ribs, vertebra), brain, lungs
    3. Kidney
    Lungs, liver, bone, brain
    4. Bones
    Lungs
    5. Thyroid
    Spinal cord
    6. Breast
    Spinal cord
    7. Esophagus
    Liver, lungs, bones, kidneys, adrenals
  6. Points to remember
    1. To produce clinical signs, the GIT bleeding should be minimum of 500 ml of blood.
    2. To demonstrate shifting dullness in abdomen, a minimum of 500 ml of fluid should be present in peritoneum.
    3. To demonstrate Puddle's sign a minimum of 120 ml of fluid should be present.
    4. To appreciate bladder fullness and to initiate micturition minimum of 400 ml of urine should be in the bladder.
      52
    5. To produce malena, the GIT bleeding must be minimum of 60 ml.
    6. Earliest anemia is seen in soft palate.
    7. Earliest jaundice seen in under surface of tongue.
    8. Earliest RVF – is ↑JVP – last to disappear is also JVP.
    9. Earliest clubbing seen in index finger.
    10. Clubbing is seen commonly in those fingers which are used mostly.
  7. If the secondaries are in
    Look for primary in
    Bone (Osteolytic changes)
    Thyroid, kidney, lower bowl, myeloma, carcinoma, breast
    Bone (Osteosclerotic or
    Prostate, Hodgkin's disease,
    Osteoblastic changes)
    carcinoid syndrome
    Lungs
    Colon and rectum, GIT, genitourinary system and breast, renal bladder, prostate, ovary, thyroid, pancreas testes, melanoma, lungs, head and neck cancer
    Liver
    Lung, GIT, breast, thyroid, pancreas, melanomas, prostate, skin
    Brain
    Bronchus, breast, kidney, thyroid, stomach, prostate, colon, malignant, melanoma, GIT and genitourinary tract, testes, etc.
    Kidney
    Lungs and liver
    Heart
    Lungs, breast, malignant, melanoma, Hodgkin's disease, leukemia, GIT, kidney
    Pericardium
    Lymphomas, breast, lungs, thyroid, pancreas, melanoma, leukemias
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    Spinal cord
    Breast, prostate, lungs, thyroid, uterus, cervix, multiple myeloma, Hodgkin's disease
    Pleura (with effusion)
    Lungs, breast, pancreas, stomach, arteries, ovary
    Cerebellum
    Colon, lungs, breast
    Skin
    Breast, prostate, kidney, head and neck, GI tract.
  8. Causes of preventable blindness
    1. Vitamin A deficiency
    2. Toxic amblyopia
      • Methyl alcohol
      • Nicotine
      • Tobacco
    3. Injury to eye
    4. Cataract
    5. Glaucoma
    6. Trachoma
    7. Diabetic retinopathy
    8. Hypertensive retinopathy
    9. Severe myopia
    10. Drugs: Steroid
      11. Infections →
      Ophthalmia neonatorium
      Herpes zoster
      12. Parasitic →
      Toxoplasma
      Onchocerca volvulus
      Cestodes
      13. Leprosy →
      Lagophthalmos – Exposure keratitis
    54
  9. Causes of herpes labialis (Herpes simplex)
    • 1. Pneumonia
    • 2. Malaria
    • 3. Rickettsial fever
    • 4. Typhoid
    • 5. Meningococcemia
    • zoom view
  10. Medical causes of epistaxis
    1. Typhoid fever anterior nasal bleed/posterior nasal bleed
    2. Rheumatic fever
    3. Pertussis
    4. Malaria
    5. Hypertension
    6. Bleeding diathesis
    7. Leukemia
    8. Snake bite – viper
    9. Scurvy
    10. Hyperviscosity syndrome
    11. Weil's disease
    12. Polycythemia vera
    13. Osler-Rendu-Weber syndrome
    14. Lepromatus leprosy
    15. Aplastic anemia
    16. Tumors of nose and pharyngeal sinuses
    17. Sinusitis of ethmoidal sinuses
    18. Drugs–Aspirin, Indomethacin, etc.–NSAID and anticoagulants
    19. Acute and chronic renal failure
  11. Onchogenic viruses
    1. Hepatitis B
    →Hepatoma
    2. Epstein-Barr virus
    →Burkitt's lymphoma
    Nasopharyngeal carcinoma
    55
    3. Herpes simplex 2 (HSV-2) virus
    → Cancer cervix
  12. Causes of impaired immunological defenses (Immunosuppressive conditions)
    1. High dose steroids
    2. Lymphoreticular malignancy
    3. Sickle cell disease
    4. Alcohol abuse (ethanol)
    5. Splenectomy
  13. Examination of conjunctiva
    • 1. Anemia
    • 2. Jaundice
    • 3. Bitot's spot
    • 4. Telangiectases
      → Ataxia telangiectasia
      5. Conjunctival suffusion
      → Leptospirosis
      6. Subconjunctival hemorrhage
      → # face, bleeding disorders
      7. Conjunctival ulcer
      → Behçet's syndrome
      8. Blue sclera
      → Marfan syndrome
      Osteogenesis imperfecta
  14. Xerostomia (Dry mouth) seen in
    1. SLE
    2. Rheumatoid arthritis
    3. Scleroderma
    4. Sjögren syndrome
    5. Polyneuritis
    6. Drugs like atropine
  15. Carotinoderma
    Carotene is converted into vitamin A in the liver with the assistance of thyroid hormone. So carotinoderma occurs in hepatic disease myxedema (It is yellow color of skin due to carotene) (better seen in palm and sole).
    56
  16. Criteria for sudden death
    1. Natural death occurring within one hour of onset of symptoms
    2. May or may not be pre-existing disease
    3. Time and mode of death is unexpected. It should be:
      • Natural
      • Unexpected
      • Rapid
      • Nonmedicolegal death
  17. Causes of sudden death
    1. Myocardial infarction
    2. MVPS
    3. Athletes after severe exercise
    4. Heavy cigarette smoking
    5. Cardiomyopathy – HOCM dilated
    6. Cardiac rupture – Rupture of ventricular aneurysm
    7. Cardiac injuries
    8. Tumors of heart – sarcoma
    9. Myocarditis
    10. Pulmonary hypertension (Primary and Secondary)
    11. Pulmonary thromboembolism
    12. Aortic stenosis
    13. Arrhythmias
  18. Hair
    1. The lifespan of length hair varies from 4 months (in eyelashes and axilla) to 4 years in scalps.
    2. The rate of growth of hair is about 1.5 to 2.2 mm per week.
    3. Graying of hair is due to loss of melanin pigment due to reduction in the number of functioning melanocytes.
  19. Sebaceous glands
    1. Seen in most part of skin
    2. Seen in abundance in scalp and face
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    3. Absent in palm and soles
    4. Act on
      • Lubricant for skin and hair
      • Has some bacteriocidal action
  20. Erythromelalgia
    No definite cause. Painful extremities often exposed to heat.
    The extremities are red and warm to touch. Seen in:
    • Rheumatoid arthritis
    • SLE
    • Diabetes mellitus
    • Hypertension
    This should be differentiated from painful cold exteriorities mainly seen in:
    • Ischemic disease
    • Neurological disorders like painful neuropathy
    • Local pathology